How many residents is too many for one nurse?

How many residents is too many residents for one nurse to safely and adequately take care of? Where I work, the nurse has anywhere from 15-25 or 30 residents, depending on what floor/hall they are on. There is two nurses per floor (each floor has the potential to house 55 residents total) on days and afternoons, however on midnights (which is what my regular shift is supposed to be starting tuesday) there is one nurse per floor and 2-3 CNAs. Now, on midnights there isnt as many meds to pass until the 6am med pass, there aren't that many sugars to check, and there aren't a huge number of medicare patients to specifically chart on (the facility's protocol is chart by exception except for medicare patients, patients on antibiotics, patients who have fallen or new admits, and any other condition that requires frequent documentation... which should be all patients in my opinion as there's a reason they are there!). So, I will have, depending on the census, up to 55 patients to myself along with 2-3 CNAs... How on earth can that be safe??? What if one patients begins to decline and I am tied up with them and another one starts to decline... there isn't two of me, and the other nurses in the building wont be able to leave their floor because they are the only ones on their floor too... Granted 911 is a call away and literally 2 minutes up the road, and the hospital is 5 minutes the other direction, but STILL - that's too many patients for one nurse to safely take care of in my opinion. Is it like this is most LTC/SNF facilities? am I being unreasonable?

At one facility, on night shift, I was responsible for 80. At another facility I was the only licensed nurse, responsible for 52. I ran into situations where, alone, I had to deal with more than one declining resident. Add to that, having a CNA or two, who were worse than worthless, made for some dicey times. Imagine having one of those nights, when the CNA, with a smile as wide as the ocean, saying that a resident fell, as she waltzes out the door. The resident fell at 2 am. Often wondered what it would be like if several of the 80 or 52 decided to have MIs as a group.

Jun 26, '11

I have 60 residents, 2-3 Great CNA's on nights at LTC. Gets a little crazy around 5am with the morning med pass and early risers. Still its unsafe with that number.

Jun 26, '11

I am a new grad RN and got my first job at a LTC facility. I can't say I hate the job as I am getting used to it. I am however sad that I do have so many residents that I don't have the time to sit down with the residents and get to know about them. My wing right now I have 25 residents on my own but I am eligible to get 2 more so I could have 27 possible. I used to have 3 CNA's but now I only have 2 which is sad because I have so many people on fall risk. I think that LTC facilities are way under staffed and feel I could do a much better job if I had half the residents to myself.

Jun 26, '11

I totally understand your concerns. LTC is a big responsibility to charge. Most people have no idea until they actually are in the setting dealing with it. I am a DON at a LTC/SNF facility. I promoted from within and charged the night shift for some time. The way it was explained to me when I voiced my concerns regarding the number of residents was that it is their HOME and not acute care and the need is not there. However, I do disagree with this. It makes it a challenge to do all that corporate requires daily plus provide good care to a demanding population. I do not suppose this will change. This is why we have falls and injury accidents. This will continue to become more complicated as we go I fear, due to the changing RAC guidelines in the hospitals. Our patient acuity levels will be more challenging because hospitals are going to have to discharge earlier. Then we will really feel the staffing/resident ratio. In reference to the question "How many is too many?" I do not have the answer. These are fire code and state mandated numbers they set for us and as long as we meet those the powers from "above" feel all is well. I do understand your concern as I have the same thought but we are fighting a losing battle on this one I think. Good luck to you and please know you are not alone.

Jun 26, '11

It may be unsafe, but unfortunately, that is about the norm. I have never worked night shift anywhere where I wasn't the only nurse IN THE BUILDING, responsible for 30-60 residents, along with anywhere from 1-4 CNAs, depending on the facility.

Jun 26, '11

Sure, on a 'good' night it might seem do-able. But being between the rock and the hard place is a typical ethical dilemma in nursing. We think we 'should' be able to do it; we think if we can just manage our time better and try a little longer to get a handle on it, it will work out okay. Until it doesn't, and there you are with your license on the line. And you don't want to be THERE, I promise you. Granted there are those who can and do do these jobs every day, every night, all across our country. Some of us feel, 'what choice do I have?' Well, you do have a choice. If you don't feel it is safe, and you're not feeling at all comfortable with the situation, don't do it. With the numbers you gave, it has the potential to get away from you real fast if the 'good' night goes bad. I am not afraid of hard work, but I wish I had realized sooner that my situation was an impossible one. Now I am realizing with great hindsight that the job I thought would give me alot of good experience was the one I should never have taken. Be cautious, and good luck.

Jun 27, '11

In my experience you have it fairly easy. The last LTC place I worked we had 96 residents with 2 RNs at night and 3 CNAs. There were multiple sticks and meds in the am. I got many of the meds changed due to they were trying to split the meds according to how many per shift. I said "Hey this is their home and why are we waking them up at 5 to give vitamins or what have you just so the night crew has meds to pass?" I won. We still did the sticks and the meds that must be given on an empty stomach etc..., but it reduced the pass drastically and many residents didn't have to be woken up unneccessarily .

Also I wanted to warn you when you say 911 is a call away make sure you know the code status of all residents. I was involved in watching a nurse call 911 on a resident who wasn't responding. This resident had been going down hill for some time. When 911 got there I went out to help the nurse and low and behold it was a resident who was a no-code. I informed the EMT and they said it was too late, that once they are called they must initiate all life saving measures.

The resident didn't make it. I am truly sad that thet poor women was assaulted and rushed out of the bed that she had become comfortable in. Her advanced directives called for no CPR, no tubes, no ABx, no extra measures only pain manaegment, O2, and suctioning as comfort care. She had no family so there was no law suit.

These types of residents should be DNR, regardless; the nurse in charge of taking care should know individual code status so wishes are followed through with.

Good luck to you. LTC is one of the most difficult positions to work.

Jun 27, '11

On the dementia unit and regular wing there are 40 residents. 1 nurse on nights and two on days and evenings. On the skilled unit there are 30 residents and one nurse on nights and two on the other shifts. 2 LNA's for each wing on nights and four to five during days and evenings. I've had 40 by myself during the day and eves years ago. but that wasn't like it is now. Today's LTC resident requires much more care then the did 12 years ago.

Jun 27, '11

We have a total of 90 residents in the building, with 4 CNAs, 2 LPNs, and 1 RN...if we're fully staffed. I am an LPN responsible for over 40 of those residents.

Jun 27, '11

I feel your pain, I worked on the rehab unit at a LTC facility. On a good day, I had 15 pretty sick rehab patients...trachs, PEGs, IVs, TPN, you name it. On a bad day, if someone called off, I had up to 30. Which is so insane, it's hard to assess, medicate and care for that many, let alone if one is going bad on you! The long term halls at my old facility had 30 patients to a nurse. The numbers are crazy at nursing homes, and they don't take into account acuity which is awful! Plus you have to deal with supervising aides, staffing, charting on Medicare patients. So my facility was sadly the same as yours. Good luck & hang in there!!

Jun 27, '11

I take care of 50 residents at night with the help of 2 nurses aides. I feel okay and confident on most nights. Yes I have bad nights where it seems everything is going wrong and super overwhelmed. On the good nights I DO stay busy, I'm definitely not sitting around twiddling my thumbs. I feel lucky if I get a lunch break. Most nights I get 10 min here or there.

Jun 27, '11

EGAD, people! It's worse out there than I thought it was! Don't you feel, sometimes, like Lucy Ricardo at the candy-packing conveyer belt?!!!!? And the supervisor comes to check and says, "You're doing great!" Then she yells to the person sending the candy through, "SPEED IT UP!"